Pediat. Radiol. 3, 53--54 (1975) 9 by Springer-Verlag 1975
Selective Adrenal Venography in an Infant with Virilizing Adrenal Cortical Carcinoma W a i t e r P. C r a i g , Jr., I r v i n F. H a w k i n s , Jr., a n d J i i r i v . K a u d e Department of Radiology, University of Florida College of Medicine, Gaines ville, Florida, USA (W.P.C., Resident; I. F. H., Associate Professor; J.V.K., Professor, Diagnostic Radiology)
Abstract. Selective adrenal venography in a 10 month old infant with adrenal cortical carcinoma and virilizing symptoms demonstrated grossly dilated, irregular tumor veins. This was an unexpected finding as at aortography no adrenal arteries which would allow selective catheterization, and only very small neoplastic vessels were seen.
Key words: Adrenal cortical carcinoma, virilizing adrenal tumor, selective adrenal venography in infancy, pediatric angiography.
W i t h b e t t e r u n d e r s t a n d i n g of t h e p h y s i o l o g y of the adrenals, virilizing adrenal cortical tumors -b e n i g n o r m a l i g n a n t - - a r e clinically d i a g n o s e d w i t h increasing frequency. Radiographically, the tumor can b e d e t e c t e d as a mass l e s i o n ( o c c a s i o n a l l y ca!cifying) o n p l a i n films of t h e a b d o m e n , o r at i n t r a v e n o u s u r o g r a p h y [2, 4]. I t can b e o u t l i n e d also b y r e t r o p e r i t o n e a l gas i n s u f f l a t i o n o r - - if l e f t s i d e d - b y g a s t r i c p a r i e t o g r a p h y [5]. I n s m a l l e r t u m o r s t h e s e m e t h o d s m a y fail, a n d b e i n g n o n - s p e c i f i c , they do not give any information about the inherent n a t u r e of t h e lesion. A o r t o g r a p h y a n d selective a d r e n a l a r t e r i o g r a p h y w i l l p r o v i d e this i m p o r t a n t p r e o p e r a t i v e i n f o r m a t i o n [1]. S e l e c t i v e a d r e n a l v e n o g r a p h y has b e e n u s e d in a f e w t e e n - a g e r s w i t h a d r e nal h y p e r p l a s i a b u t t h e r e is n o r e p o r t o n t h e m e t h o d in i n f a n t s w i t h a d r e n a l c o r t i c a l c a r c i n o m a [1, 3].
the veins emptied into the dilated renal vein after 6 s. With both aortographic and venographic findings the diagnosis of adrenal carcinoma was made. At surgery, the gross specimen correlated with angiographic findings. The histological diagnosis was adrenal cortical carcinoma. Postoperative recovery was uneventful.
Discussion T h e case p r e s e n t e d illustrates t h e f e a s i b i l i t y of a d r e n a l v e n o g r a p h y in i n f a n c y , a l t h o u g h d i l a t a t i o n of t h e left a d r e n a l v e i n o b v i o u s l y f a c i l i t a t e d selective c a t h e t e r i z a t i o n o f this vessel. T h e f i n d i n g s at a o r t o -
Case Report 10 month old female with virilizing symptoms (appearance of pubic hair and enlargement of the clitoris; increased pigmentation) noted one month prior to admission. Intravenous urography showed depression of the left kidney, compatible with an upper pole or adrenal mass. At aortography a well defined adrenal tumor of 8 cm in size was demonstrated (Fig. 1). The tumor was poorly vascularized but tiny neoplastic vessels were thought to be present. For a better demonstration of these by selective arteriography no adrenal artery large enough to be catheterized could be identified. We decided to attempt selective adrenal venography. Following percutaneous puncture of the left femoral vein a French 4 polyethylene catheter shaped as a shepard's crook with a Iong side arm was inserted. The left adrenal vein was easily catheterized without any catheter manipulation instrument. At test injection dilated adrenal veins were seen. 22 mI Renografin 60(~) was injected at a rate 6 ml/s. Grossly dilated, irregular veins were flled in the tumor (Fig. 2). The flow was slow but there was no evidence for venous obstruction and
Fig. 1. Aortogram, late arterial phase. Well defined, poorly vascularized tumor of the left adrenal with depression of the left kidney
54
W.P. Craig, Jr. el aL : Selective Adrenal Venography We do not have any satisfactory explanation for the peculiar discrepancy between the small adrenal arteries and the gross dilatation of the veins. One w o u l d expect that -- if the venous dilatation was caused by increased blood flow to the t u m o r -- the arteries w o u l d be also increased in size. In a necrotic t u m o r with decreased arterial supply the veins should be smaller. Venous obstruction as a cause for dilatation was not present. Hopefully, selective adrenal v e n o g r a p h y w h e n more extensively used should add to our knowledge of the appearance of the veins in adrenal cortical carcinoma - a t u m o r which is becoming more frequently diagnosed in infancy and childhood.
z/:~eferelIs
Fig. 2. Selective adrenal venography. In contrast to the small neoplastic vessels filled at aortography, grossly dilated veins in the left adrenal tumor are demonstrated. With the use of a 0.3 mm focal spot appr. 1.8 fold geometric magnification was applied at serial radiography graphy indicated malignancy but the diagnosis could not be confirmed by selective adrenal arteriography. A l t h o u g h we did not have any previous experience with v e n o g r a p h y in adrenal cortical tumors in infancy we t h o u g h t that the presence of large irregular veins within the t u m o r supported the diagnosis of malignacy rather than that of a benign adenoma.
1. Bron, K. M., Riley, R. R., Girdany, B. R.: Pediatric at> giography in abdominal and extremity lesions. Radiology 92, 1241 (1969) 2. Ke•ny, F. M., Hashida, Y., Askari, A., Sieber, W. H., Fetterman, G. H. : Virilizing tumors of the adrenal cortex. Amer. J. Dis. Child. 118, 445 (1968} 3. Nicotis, G. L., Mitty, H. A., Modlinger, R. S., Gabrilove, J. L. : Percutaneous adrenal venography. Ann. Int. Med. 76, 899 (1972) 4. Tenenbaum, J. : Carcinoma of the adrenal cortex. J. Urol. 42, 277 (1939) 5. Werblinska, B., Winnicki, S., Hroboni, T.: A case of malignant tumor in the adrenal cortex in a child. Pol. Rev. Radiol. Nucl. Med. 36, 453 (1972) Jiiri Kaude, M. D. P. O. Box 730 Dept. of Radiology J. Hillis Miller Health Center Gainesville, FL 32610 USA
Selective Adrenal Venography in an Infant with Virilizing Adrenal Cortical Carcinoma W a i t e r P. C r a i g , Jr., I r v i n F. H a w k i n s , Jr., a n d J i i r i v . K a u d e Department of Radiology, University of Florida College of Medicine, Gaines ville, Florida, USA (W.P.C., Resident; I. F. H., Associate Professor; J.V.K., Professor, Diagnostic Radiology)
Abstract. Selective adrenal venography in a 10 month old infant with adrenal cortical carcinoma and virilizing symptoms demonstrated grossly dilated, irregular tumor veins. This was an unexpected finding as at aortography no adrenal arteries which would allow selective catheterization, and only very small neoplastic vessels were seen.
Key words: Adrenal cortical carcinoma, virilizing adrenal tumor, selective adrenal venography in infancy, pediatric angiography.
W i t h b e t t e r u n d e r s t a n d i n g of t h e p h y s i o l o g y of the adrenals, virilizing adrenal cortical tumors -b e n i g n o r m a l i g n a n t - - a r e clinically d i a g n o s e d w i t h increasing frequency. Radiographically, the tumor can b e d e t e c t e d as a mass l e s i o n ( o c c a s i o n a l l y ca!cifying) o n p l a i n films of t h e a b d o m e n , o r at i n t r a v e n o u s u r o g r a p h y [2, 4]. I t can b e o u t l i n e d also b y r e t r o p e r i t o n e a l gas i n s u f f l a t i o n o r - - if l e f t s i d e d - b y g a s t r i c p a r i e t o g r a p h y [5]. I n s m a l l e r t u m o r s t h e s e m e t h o d s m a y fail, a n d b e i n g n o n - s p e c i f i c , they do not give any information about the inherent n a t u r e of t h e lesion. A o r t o g r a p h y a n d selective a d r e n a l a r t e r i o g r a p h y w i l l p r o v i d e this i m p o r t a n t p r e o p e r a t i v e i n f o r m a t i o n [1]. S e l e c t i v e a d r e n a l v e n o g r a p h y has b e e n u s e d in a f e w t e e n - a g e r s w i t h a d r e nal h y p e r p l a s i a b u t t h e r e is n o r e p o r t o n t h e m e t h o d in i n f a n t s w i t h a d r e n a l c o r t i c a l c a r c i n o m a [1, 3].
the veins emptied into the dilated renal vein after 6 s. With both aortographic and venographic findings the diagnosis of adrenal carcinoma was made. At surgery, the gross specimen correlated with angiographic findings. The histological diagnosis was adrenal cortical carcinoma. Postoperative recovery was uneventful.
Discussion T h e case p r e s e n t e d illustrates t h e f e a s i b i l i t y of a d r e n a l v e n o g r a p h y in i n f a n c y , a l t h o u g h d i l a t a t i o n of t h e left a d r e n a l v e i n o b v i o u s l y f a c i l i t a t e d selective c a t h e t e r i z a t i o n o f this vessel. T h e f i n d i n g s at a o r t o -
Case Report 10 month old female with virilizing symptoms (appearance of pubic hair and enlargement of the clitoris; increased pigmentation) noted one month prior to admission. Intravenous urography showed depression of the left kidney, compatible with an upper pole or adrenal mass. At aortography a well defined adrenal tumor of 8 cm in size was demonstrated (Fig. 1). The tumor was poorly vascularized but tiny neoplastic vessels were thought to be present. For a better demonstration of these by selective arteriography no adrenal artery large enough to be catheterized could be identified. We decided to attempt selective adrenal venography. Following percutaneous puncture of the left femoral vein a French 4 polyethylene catheter shaped as a shepard's crook with a Iong side arm was inserted. The left adrenal vein was easily catheterized without any catheter manipulation instrument. At test injection dilated adrenal veins were seen. 22 mI Renografin 60(~) was injected at a rate 6 ml/s. Grossly dilated, irregular veins were flled in the tumor (Fig. 2). The flow was slow but there was no evidence for venous obstruction and
Fig. 1. Aortogram, late arterial phase. Well defined, poorly vascularized tumor of the left adrenal with depression of the left kidney
54
W.P. Craig, Jr. el aL : Selective Adrenal Venography We do not have any satisfactory explanation for the peculiar discrepancy between the small adrenal arteries and the gross dilatation of the veins. One w o u l d expect that -- if the venous dilatation was caused by increased blood flow to the t u m o r -- the arteries w o u l d be also increased in size. In a necrotic t u m o r with decreased arterial supply the veins should be smaller. Venous obstruction as a cause for dilatation was not present. Hopefully, selective adrenal v e n o g r a p h y w h e n more extensively used should add to our knowledge of the appearance of the veins in adrenal cortical carcinoma - a t u m o r which is becoming more frequently diagnosed in infancy and childhood.
z/:~eferelIs
Fig. 2. Selective adrenal venography. In contrast to the small neoplastic vessels filled at aortography, grossly dilated veins in the left adrenal tumor are demonstrated. With the use of a 0.3 mm focal spot appr. 1.8 fold geometric magnification was applied at serial radiography graphy indicated malignancy but the diagnosis could not be confirmed by selective adrenal arteriography. A l t h o u g h we did not have any previous experience with v e n o g r a p h y in adrenal cortical tumors in infancy we t h o u g h t that the presence of large irregular veins within the t u m o r supported the diagnosis of malignacy rather than that of a benign adenoma.
1. Bron, K. M., Riley, R. R., Girdany, B. R.: Pediatric at> giography in abdominal and extremity lesions. Radiology 92, 1241 (1969) 2. Ke•ny, F. M., Hashida, Y., Askari, A., Sieber, W. H., Fetterman, G. H. : Virilizing tumors of the adrenal cortex. Amer. J. Dis. Child. 118, 445 (1968} 3. Nicotis, G. L., Mitty, H. A., Modlinger, R. S., Gabrilove, J. L. : Percutaneous adrenal venography. Ann. Int. Med. 76, 899 (1972) 4. Tenenbaum, J. : Carcinoma of the adrenal cortex. J. Urol. 42, 277 (1939) 5. Werblinska, B., Winnicki, S., Hroboni, T.: A case of malignant tumor in the adrenal cortex in a child. Pol. Rev. Radiol. Nucl. Med. 36, 453 (1972) Jiiri Kaude, M. D. P. O. Box 730 Dept. of Radiology J. Hillis Miller Health Center Gainesville, FL 32610 USA
